ANIMAL REGISTRATION FORM

LOWELL
Lowell Animal Shelter 218 N Lincoln Lowell, AR 72745 Phone 479-202-6363 opt. 4 Fax 479-659-0302
ANIMAL REGISTRATION FORM
Owner's Name*
Physical Address*
Zip*
City*
State*

Home Phone*
Work Phone
Cell Phone
Email*
example@example.com

Emergency Contact Person: (someone other than yourself)
Emergency Contact Person*
Relationship
Phone*
Secondary Phone

Pet Name
Breed(s)
Color(s)
Age
Date you acquired animal

MonthDayYear
Date
Is your pet spayed or neutered?
(Must provide a copy of Rabies Certificate)
Date of Rabies Vaccine

MonthDayYear
Date

Vet's Name
Vet's Phone
Microchip Number
Microchip Company
Signature
Form may be dropped off at the Animal Shelter, faxed to 479-659-0302, emailed to animalcontrol@lowellarkansas.gov, or mailed to 216 N Lincoln, Lowell, AR 72745.
Should be Empty: